The URL can be used to link to this page

B-19-906 - 0011 ANDREW STREET - Building Permit C:Ac-. i©3 The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF k Massachusetts State Building Code,780 CMR SALEM \; Revised Mar 2011 Q Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling ` This Section For Official Use Only Building Permit Number:. Date Applied: �. ka 8-a ' Building Official(Print Naive) gignature V Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers tL A aS L l a Is this an accepted street?yes-V no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning 6istrict Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 ]Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Gone: _ Outside Flood Zone? Public Private❑ Check if yes❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: �� 1.\5��M� J1b A�� Sd G 15�ei� Sa.1e Aj MA� 611*3C Name(Print) City,State,ZIP No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that.apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work2: d 4 3' S C�i7ll� Of W QLL, 7-0l�vl�j/fo C/ Daor op-eylaly, SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item Official Use Only (Labor and Materials) 1.Building $ 2 Z 1. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee2.Electrical $ a©O ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: � 5.Mechanical (Fire Suppression) $ Total.All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 2, C> ❑Paid in Full ❑Outstanding Balance Due: .c,Q 0G()A11t-- 'S /zi M P►r✓� i SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) AQ' ,ihTGS License Number Expiration Date Name of CSL Holder List CSL Type(see below) 7 r- o L 13<q T-,f No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft.) City/town,State,ZIP C% R Restricted 1&2 Family Dwelling M Masonry RC Roofing Covering — WS Window and Siding SF Solid Fuel Burning Appliances I Insulation ele hone Email address D Demolition 5.2 ]Registered Home Improvement Contractor(HIC) Iq S d � n S S `2/ l�T h Lap pfh H C Registration Number Expiration Date HIC Company Name or HJ'C Registp6nt Name ,1Z1±784 l P/'YgC 1Nr o e No.and Street Email address MC411 HIU 4yt�- l7e 7-:)-M- 5` City/Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the IssuaX of the building permit. Signed Affidavit Attached? Yes.......... No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIpE�S FOR BUILDING PERMIT 1,as Owner of the subject property,hereby authorize �,vl�S to a(;t on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) U Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. Li3c, be,\,%5i)t> 1 6-) Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/das 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"maybe substituted for"Total Project Cost" I 1 August 18, 2019 11 Andrew St. Salem, MA 01970 To Wham It May Concern: The 11 Andrew Street Condominium Association is aware that Unit B is having work done, and we approve of that work. Sincerely, . Lynn darner Signatory 11 Andrew Street Condominium Association i i ., CITY OF S.0 Etii, 1LksSACHUSETTS • BUILDING DEPARTMENT 'f 120 WASHINGTON STREET,r FLOOR TE - (978)745-9595 FA.x(978)740-9846 KI,%,fBERLEIf DRISCOLL tijAtiYOR Trto>►tas ST.PIERRfi DIRECTOR OF PUBLIC PROPERTY/BUILDING CO%LNUSSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumben Applicant Information /y. Please Print Legibly Naltne(BusintssiOrganization/Individual): 1c/1-t9 es - Address: '7 CoLy !tiI l�/�l. �-e1K�e e City/State/Zip: '4�l/'6 fk'b kt_//& t3/�y Phone : 7 —>PC/ Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 4. ® 1 am a general contractor and 1 6. ❑N w construction mployees(full and/or part-time).* have hired the sub-contractors 2.[jJ am a sole proprietor or partner- listed on the attached sheet.: 7. Remodeling ship and have no employees These sub-contractors have 8. Q Demolition workingfor me in an capacity. workers'comp.insurance. Y � tY• 9. ❑Building addition [No workers'comp.insurance S. ❑ We are a corporation and its 10.Q Electrical repairs or additions required,] officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL I t.❑Plumbing repairs or additions myself.[No workers'camp. C. 152,§1(4),and we have no 12.0 Roof repairs insurance required.)t employees.[No workers' 13[]Other comp.insurance required.] *Any applicant that checks box ill must also fill uut the section below showing their workers'compensation policy information. 'I Inimpwoas who submit this affidavit indicating they are doing all work and then hire outside contract=mutt submit a new affidavit indicating such. =Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'romp.polity I rotrruttiaa. 1 am an employer that is providing workers'compensation Insurance for my employees. Below Is the policy and Job site inform,ution. Insurance Company dame: Policy 4 or Sclf-ins.Lic.ti: Expiration Date- Job Site Address: City/State/zip: Attache a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby ccertifyy under the pains and penalties of perjury that the information provided above is true and correct: Date, Phone# Official use only. Do not write in this area6 to be completed by city or town official City or Town: PermittLicense N issuing Authority(circle one): 1.Huard of health 2.Building Department 3.CityrTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: _� Phone#-. i CITY OF S��LEM i� -kSSACHUTSETTS • BLILDIING DEPkRT\1NT \ 120 WASHINGTON STREET,31O FLOOR TEL. (978) 745-9595 FAX(978) 740-9846 iU�iBERt FY)DRISCOLL MAYOR TrTOMAs ST.PTERRs DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\LNUSSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) 'In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris,.and the provisions of MGL c 40, S 54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111, S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in (name of facility) (address of facility) signature g tore of permit applicant date I debrisaf ..doc I CITY OF SALEM, MASSACHUSETTS Building lmoector�' ® 98 Washington Street, 2"d Fldor- Salem; Massachusetts' c01970 I ��+ leEw m Ds d l Once \ ' \\ \ + f F �\\ `\\\ \\\ t /i / � f i /� ///! // f .Office of Consumer Affairs&Business Regulation ~� HOME IMPROVEMENT CONTRACTOR TyE Individual Reais ion expiration a 05/06/2021 JAMES MCINTfi� {w. { D/B/A MCINTQ YY ER =y WJ JAMES C.MCIN .Q 7 COLUMBIA TER`FCk.F;<�"a HAVERHILL,MA 01830' Undersecreta %. fi r v Nib Commonwealth of Massachusetts rt " r .Division of Professional ticensure Board of Building Regulations.and Standards Constr, 947,ryisor C$-111830 E [Dires RAD MCI ::'07/21/2021 JAMES CON f n N - 12 PRINCE STk,EET SALEM MA 01gx0 } Ccsrtl.missloner. yr ,.